Programmes for advance distribution of misoprostol to prevent post-partum haemorrhage: a rapid literature review of factors affecting implementation

Abstract

Recent efforts to prevent post-partum haemorrhage (PPH) in low-income countries have focused on providing women with access to oral misoprostol during home birth. The WHO recommends using lay health workers (LHWs) to administer misoprostol in settings where skilled birth attendants are not available. This review synthesizes current knowledge about the barriers and facilitators affecting implementation of advance community distribution of misoprostol to prevent PPH, where misoprostol may be self-administered or administered by an LHW.We searched for and summarized available empirical evidence, and collected primary data from programme stakeholders about their experiences of programme implementation.We present key outcomes and features of advanced distribution programmes that are in operation or have been piloted globally. We categorized factors influencing implementation into those that operate at the health system level, factors related to the community and policy context and those factors more closely connected to the end user.Debates around advance distribution have centred on the potential risks and benefits of making misoprostol available to pregnant women and community members during pregnancy for administration in the home. However, the risks of advance distribution appear manageable and the benefits of self-administration, especially for women who have little chance of expert care for PPH, are considerable.

Evaluation of different models of access to misoprostol at the community level to improve maternal health outcomes in Ethiopia, Ghana, and Nigeria

“…The global evidence in support of advanced distribution of misoprostol to women to prevent postpartum hemorrhage is clear and incontrovertible; there is no further need for pilot studies to demonstrate the feasibility or effectiveness of this approach [7,30,31]. Nonetheless, the present evaluation found that a pervasive lack of trust in women's capabilities to use misoprostol correctly and the widely held belief that women might “misuse” the pills (for abortion) persist, despite a lack of evidence.…”

Effect of community-based distribution of misoprostol on facility delivery: a scoping review

“…Women were found to have no major problem of misusing the drug and it was found to be acceptable by them [16]. Another rapid review of the literature showed that distribution of misoprostol in advance of delivery by lay health workers for selfadministration was feasible and acceptable at all levels-end-user, health system, community, and policy [20,25].…”

“…Misoprostol has been studied in different setups and is endorsed by the World Health Organization (WHO) as a solution for women who give birth in facilities without oxytocin or where there is low coverage of skilled attendance [16]. Clinical trials have verified the effectiveness and safety of community distribution of misoprostol [20,17,21,14] where access to skilled birth attendance and oxytocin is limited. A pooled estimate of randomized controlled trials (RCT) comparing 600μg of oral or sublingual misoprostol with placebo in primary care or home delivery settings show that misoprostol resulted in 24% and 41% reductions in the incidence of PPH and severe PPH compared with placebo, respectively [17].…”

“…Despite the existing evidence, community-based distribution of misoprostol is still the least prioritized intervention in the maternal survival strategies [22-24, 18, 25]. This is due to concerns of policymakers' and practitioners' [21,17,25,12] that misoprostol distribution at community level might decrease facility deliveries, possibly lead to misuse of misoprostol (including taking the drug before delivery, and using the drug for the purpose of inducing abortion), and lack of technologies and expertise to diagnose multiple pregnancies before using it at community levels in resourcelimited settings [20,26]. A range of other barriers at the health system, community, and policy levels are also impeding access to misoprostol for prevention of PPH.…”

“…A range of other barriers at the health system, community, and policy levels are also impeding access to misoprostol for prevention of PPH. These barriers include: 1) absence of registration of misoprostol for the management of PPH [27,25], 2) fear and apprehensions of providers and policymakers regarding its use [27,25], 3) lack of evidence-based guidelines and provider training [25], 4) inadequate staffing and lack of knowledge and skill of providers regarding causes of PPH, and 5) limited knowledge of the community regarding the appropriate dosage and timing of administration for PPH presentation and management [27,20].…”